Provider Demographics
NPI:1467663492
Name:COMMUNITY MEMORIAL HEALTH SYSTEM
Entity Type:Organization
Organization Name:COMMUNITY MEMORIAL HEALTH SYSTEM
Other - Org Name:SANTA PAULA URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-652-5011
Mailing Address - Street 1:2705 LOMA VISTA RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-1581
Mailing Address - Country:US
Mailing Address - Phone:805-667-2801
Mailing Address - Fax:805-667-2865
Practice Address - Street 1:242 E HARVARD BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:SANTA PAULA
Practice Address - State:CA
Practice Address - Zip Code:93060-3372
Practice Address - Country:US
Practice Address - Phone:805-525-9595
Practice Address - Fax:805-525-6667
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY MEMORIAL HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-24
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM08609FMedicaid
CARHM08609FMedicaid
CARHM08609FMedicaid